Brash syndrome

Background

• Combination of following:
  • Bradycardia
  • Renal failure
  • AV node blocker: beta-blocker, verapamil or diltiazem
  • Shock
  • Hyperkalemia
• Vicious cycle in setting of medications, hyperkalemia, renal failure
• Renal failure causes hyperkalemia and accumulation of AV node blockers, hyperkalemia synergizes with AV node blockers to cause bradycardia and hypoperfusion, hypoperfusion worsens renal failure

Clinical Features

• Asymptomatic or symptomatic bradycardia
• Multisystem organ failure (shock, pulmonary edema, renal failure, shock liver)
• Altered mental status

Differential Diagnosis

• Differential bradycardia
• Differential renal failure
• pure hyperkalemia
• pure AV node blocker intoxication

Evaluation

• Brash syndrome patients can have mild hyperkalemia while pure hyperkalemia to cause bradycardia usually requires more dramatic elevation of potassium level
• ECG findings with bradycardia without other findings of hyperkalemia (QRS widening, peaked T waves) may favor BRASH
• pure AV blocker intoxication may or may not have hyperkalemia, need in BRASH. BRASH syndrome patients typically adherent to medications, not usually large ingestion

Management

• Hyperkalemia treatment
• Fluid resuscitation if hypovolemia